INHALED NITRIC OXIDE (iNO) PROTOCOL - …

1 INHALED NITRIC OXIDE (iNO) PROTOCOLI ndications for <100 mmHg on FiO2 100% saturations <92% on FiO2 100% of PPHN on FiO2 60% by:1. Echo2. Clinical judgment if echo Index (OI) 25A. INITIATION OF THERAPY (>34 WK)Start iNO at 20 ppmPaO2 response >20 mmHgStop iNOGet ABG30 minBegin weaningFiO2 within 4 hrsFiO2 wean by 2 5% q30 min for preductal sat 92%, PaO2 >60 mmHg, and pre post sat difference 5%FiO2 to 60%Notify MD; wean iNO(see part B)Do not wean iNO; continue FiO2 wean attemptsYESNOYESNOINHALED NITRIC OXIDE (iNO) PROTOCOLB. WEANING PROTOCOL (>34 WEEKS)20 ppmSaturations >5%10 ppm5 ppm4 ppm30 minYESYES1. Weaning Considerations2. If patient falls below the success criteria, return to previous settings and try again in 4 hrs if no lability3. If there are 2 unsuccessful weans in 12 hrs, hold weaning for 12 24 hrs4. Consider adjunct therapies:a. Sildenafil mg/kg IV q6 hrs; titrate up to 4 6 mg/kg/dayDiscontinue iNO Obtain ABG If PaO2 <75 or saturations 5%, restart iNONOS aturations >5%30 minNOSaturations >5%60 min3 ppm2 ppmSaturations >5%60 minNOSaturations >5%60 minNOYES1 ppmYESNOYESS aturations >5%The Neonatal INHALED NITRIC OXIDE Study Group: 1997A INHALED NITRIC OXIDE in full term and nearly full term infants with hypoxic respiratory failure.

2 N Eng J Med 336:597 604 INHALED NITRIC OXIDE (iNO) PROTOCOLC. iNO THERAPY <34 WEEKS5 ppmChecklist prior to with lung volumes optimized on Chest X document PPHN and rules out congenital heart corrected with vasoactive agents and volume as indicatedOxygenation Response Post ductal saturation 90% PaO2 >60 mmHg on FiO2 100%30 min1. Increase by 5 ppm to max 20 ppm; check response at each step*2. Wean FiO2 to 60% and then begin iNO weanNO1. Wean FiO22. Discontinue iNO over next 2 4 hrsYESD. WEANING PROTOCOL <34 WEEKS* BG q15 minutes x220 ppm10 ppm Wean FiO2 to 60% over 1 2 hrs; then begin iNO wean in 1 2 hrs Check BG in 15 minutes after iNO initiation May wean with post ductal saturations >85% and PaO2 >60 mmHgReturn 1 step if failure to wean 5 ppm2 ppm1 ppmDiscontinue iNO 5 minutes without ventilator/FiO2 changes Wean over 1 2 hours 5 min without ventilator/FiO2 changes Wean FiO2 <50% Wean iNO over 1 4 hours No evidence of shunting; normal pH 5 min without ventilator/FiO2 changes Observe for 30 minutes 5 min without ventilator/FiO2 changes Observe for 30 minutes; pre oxygenate for 10 minutes with FiO2 by 5 min without ventilator/FiO2 changes Observe for 30 minutes; then FiO2 by q30 min.

3 Back to baseline Failure to Wean: in preductal postductal O2 saturation difference by >5% within 5 minutes of weaning, with no change in vital signs/ventilator settings/FiO2 to previous iNO dose and re attempt weaning in 1 2 JP, et al. Early INHALED NITRIC OXIDE therapy in premature newborns with respiratory failure. N Engl J Med 2006;355:354 64 Hibbs AM, et al. One year respiratory outcomes of preterm infants enrolled in the NITRIC OXIDE Chronic Lung Disease Trial J Peds 2008;153(4):525 29 INHALED NITRIC OXIDE (iNO) PROTOCOLC hecklist prior to to be in hypoxic respiratory failure or documented pulmonary hypertension per volumes optimized on SIMV/HFOV and CXR shows good expansionE. CONGENITAL DIAPHRAGMATIC HERNIA AND BRONCHOPULMONARY DYSPLASIA/CLD20 ppmOxygenation Response Post ductal saturation >95% PaO2 increased by 10 20 mmHg from baseline at 1 hr following initiation (check ABG at 1 hr no vent changes to be made during this time)1.

4 Maintain iNO (max of 96 hrs)2. Start on Sildenafil:a. mg/kg PO q 6hrb. Titrate up to 4 6 mg/kg/day3. Follow iNO weaning PROTOCOL (see Part B)4. If continuing for >96 hours, will require approval of two physicians with daily reviewDiscontinue iNO therapy, or plan for wean over next 4 6 hrsResponderNon ResponderThe current literature does not support the use of iNO in established BPD/CLD and CDH infants. The role of iNO in treating pulmonary hypertension in CDH infants remains controversial